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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4572_Библиотеки_им_академика_М_И_Перельмана
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Part V: Clinical Case 3
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Preoperative Assessment
1. Frontolateral walls
Small, flat tip which was ill defined and amorphously
continuous with the wide flat alae nasi on both sides
(Frontal, Direct Dorsal, Backward Tilting and Basal
Views).
2. Nasal septum
Nil of note.
3. Bony pyramid
Wide base, flat bony pyramid (preoperative Frontal,
Direct Dorsal, Backward Tilting, Oblique and Lateral
Views).
4. Alar base
a. Wide alar base due to long inferior and bulky poste-
rior segments of the rim-sill folds. The posterior
segments have acute alar lip angles i.e. flat tire
appearance (Pre-operative Basal and Nasal Aperture
Views).
b. Note that the right rim-sill fold was stretched by the
testing probe (Right rim-sill test).
Aims of Surgery
1. Provide good tip definition and tip projection.
2. Elevation and narrowing of the boney pyramid.
3. Reduction of the bulk and width of the alar base with
transformation of the horizontal axes of the nasal openings into vertical ones.
Surgical Plan
1. Frontolateral walls
a. DDD excluding the weak triangle to reduce the bulk
of the nasal tip.
b. Bilateral cephalic trim of lateral crurae to reduce the
size of the nasal tip.
35
2. Nasal septum
Nil of note.
3. Bony pyramid
Osteotomies and medialization of the lateral bony walls.
4. Alar base
Resection of the posterior and inferior segments of the
rim sill folds.
Surgical Procedure
1. As per Surgical Plan.
2. Nasolabial and supratip cartilage grafts were needed.
Post-operative Analysis
1. Frontolateral Wall
a. Tip definition: the nasal tip is slimmer, more promi-
nent and well identified from the alae nasi on both
sides. The alae nasi become clearly visible and share in
nasal aesthetics (Frontal, Direct Dorsal, Overhead,
Backward Tilting and Basal Views).
b. Tip projection: the nasal tip is at the same level of the
nasal dorsum with good aesthetic angle. This is
coupled with good aesthetic nasolabial angle (lateral
and oblique views).
c. Tip light reflex is seen as one spot off the nasal tip
(Frontal and Backward Tilting Views).
2. Medial Wall
Nil of Note.
3. Bony Pyramid
a. Bony pyramid aesthetics: the nasal dorsum is high,
straight and the sidewalls are smooth and narrow (all
views except the Basal Views).
b. Dorsal light reflex is seen as a regular one line off the
nasal dorsum (Direct Dorsal Views).
4. Alar Base
a. Superior alar groove aesthetics improved by defatting.
The grooves became longer and deeper (Oblique,
Lateral and Direct Dorsal grooves).
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty,
https://doi.org/10.1007/978-3-031-12271-2_35
203
204 35 Part V: Clinical Case 3
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b. Posterior alar groove aesthetics improved by excising
the posterior segment of the rim-sill folds. Flat tire
appearance is no longer present (Backward Tilting,
Basal and Nasal Aperture Views).
c. Nasal aperture aesthetics:
i. The size of the nasal openings are reduced by
defatting of the frontolateral walls and resection
of the rim-sill folds.
ii. The shape of nasal openings: defatting and
resection of the rim-sill folds enhanced the aesthetics of the nasal openings. They become more
elegantly oval in shape (Backward Tilting, Basal
and Nasal Aperture views).
d. Alae nasi aesthetics improved. They are pulled
medially become better seen, smaller and share in
nasal aesthetics (Nasal Aperture, Oblique and Lateral
Views).
e. Marginal light reflexes are clearly seen at:
i. Inferior alar margins (Nasal Aperture Views).
Frontal
ii. Nasal sill bands (Oblique Views).
iii. Lateral crural prominences (Lateral Views).
Commentary
a. The overall wide flat, thick skinned heavy looking nose
was transformed into slim, high thin skinned gentle looki ng
nose. The overall size and bulk of the nose was reduced.
b. Three of the four areas of Rhinoplasty were addressed i.e.
the frontolateral walls, the bony pyramid and the alar
base. No tip or dorsal grafts were used. The supratip and
nasolabial grafts were needed in these junctional areas for
aesthetic enhancement. They neither affect the natural
soft sensation of the nose, nor do they affect the normal
physiological mobilities of the nose.
c. These changes had such a positive boost to the patient’s
psychology that he changed his career from a car
mechanic to a sales representative in a famous food
company.
Frontal
Smiling
Frontal
Middle Third
Preoperative
Postoperative
35 Part V: Clinical Case 3 205
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Direct Dorsal
Direct Dorsal
Preoperative
Postoperative
Smiling
Preoperative
Postoperative
Backward Tilting
Steeper
Backward Tilting
Basal
Basal
Smiling
206 35 Part V: Clinical Case 3
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Preoperative
Postoperative
Right Nasal
Aperture
Right Oblique
Mid Cheek
Full Face
Right Nasal
Aperture
Rim Sill Test
Left Nasal
Aperture
Rim Sill Test
Left Oblique Right Oblique
Mid Cheek Mid Cheek
Full Face Middle Third
Left Nasal
Aperture
Left Oblique
Mid Cheek
Middle Third
Preoperative
Postoperative
35 Part V: Clinical Case 3 207
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Preoperative
Postoperative
Right Oblique
Cheek Margin
Full Face
Left Oblique Right Oblique
Cheek Margin Cheek Margin
Full Face Middle Third
Left Oblique
Cheek Margin
Middle Third
Preoperative
Postoperative
Right Lateral
Left Lateral
Right Lateral
Smiling
Left Lateral
Smiling
208 35 Part V: Clinical Case 3
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Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
Part V: Clinical Case 4
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36
Preoperative Assessment
1. Frontolateral walls
a. Nasal tip is slightly elevated and tilted backwards
(Lateral and Oblique Views).
b. The nasal tip felt hard and solid when palpated sec-
ondary to previous surgery.
2. Media Wall
Nil of note.
3. Bony pyramid
a. Wide base of boney pyramid. No signs of previous
surgery in this area (Direct Dorsal and Backward
Tilting Views).
b. The bony pyramid is small in size and length, as seen
in a child’s nose, confirmed by palpation.
c. The dorsum is flat and ill defined. The upper two
thirds of the nose is dissociated from the nasal tip
(Frontal, Direct Dorsal and Backward Tilting
Views).
4. Alar base
Previous alar base surgery.
Aims of Surgery
To enhance the aesthetics of nasal dorsum and sidewalls of
the bony pyramid and mid vault.
4. Alar base
Nil of note.
Surgical Procedure
As per Surgical Plan.
Post-operative Analysis
a. Bony pyramid aesthetics: the bony pyramid was not
touched in the previous surgery. It was dealt with as
primary surgery. The nasal bones are short and small
compared to the size of the nose. Osteotomies alone
would not have been sufficient to give enough height to
the dorsum. Additional height by using a septal graft was
necessary.
b. The dorsal graft has achieved the following:
i. Elevated the nasal dorsum.
ii. Increased the size of the nose.
iii. Increased the length of the nose which had conse-
quently corrected the backward tilt of the nasal tip
and pushed it down to a better aesthetic position.
iv. Improved the visual effect of the large forehead,
cheeks and protruding chin.
c. Dorsal light reflex of nasal dorsum appears as one
uninterrupted line (Direct Dorsal Views).
Surgical Plan
1. Frontolateral walls
Nil of note.
2. Media Wall
Harvesting cartilage and boney septal grafts.
3. Bony pyramid
a. Osteotomies and medialization of the lateral bony
walls.
b. Dorsal septal graft.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty,
https://doi.org/10.1007/978-3-031-12271-2_36
Commentary
a. The middle third photographs in this lady are well
appreciated. In full face photographs the large sizes of the
forehead, cheeks and mandibles over shadow the small
size of the nose. Aesthetics of the nose are not very well
appreciated, but the patient is quit e aware of any minor
changes in her small nose.
b. This case is all about making the correct decisions. The
primary surgeon should have attempted to increase the
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size, height and the length of the nose rather than reducing
its size.
c. No attempt was made to explore the nasal tip. As tissues
were quite tough and fibrosed any surgical modification
would have been risky.
Preoperative
d. The nasal tip and the alae nasi looked apparently large
pre-operatively taking 1/2 of the total size of the nose.
Post-operatively the natural proportionate sizes of the
upper two thirds and lower third was regained.
Frontal
Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
Postoperative
36 Part V: Clinical Case 4 211
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Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
Right Nasal
Right Nasal
Aperture
Aperture
Rim Sill Test
Basal
Left Nasal
Aperture
Rim Sill Test
Basal
Smiling
Left Nasal
Aperture
Preoperative
Postoperative
212 36 Part V: Clinical Case 4
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Preoperative
Postoperative
Right Oblique
Mid Cheek
Full Face
Left Oblique
Mid Cheek
Full Face
Right Oblique
Mid Cheek
Middle Third
Preoperative
Postoperative
Right Oblique
Cheek Margin
Full Face
Left Oblique Right Oblique
Cheek Margin Cheek Margin
Full Face Middle Third
Left Oblique
Cheek Margin
Middle Third
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